Management of Care Q 15

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A triage nurse has these four (4) clients arrive in the emergency department within 15 minutes. Which client should the triage nurse send back to be seen first?

  

     A. A 2-month-old infant with a history of rolling off the bed and has bulging fontanelle with crying

     B. A teenager who got a singed beard while camping

     C. An elderly client with complaints of frequent liquid brown colored stools

     D. A middle-aged client with intermittent pain behind the right scapula

    

    

Correct Answer: B. A teenager who got a singed beard while camping

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This client is in the greatest danger with a potential of respiratory distress. Any client with singed facial hair has been exposed to heat or fire in close range that could have caused serious damage to the interior of the lungs. Note that the interior lining of the lungs has no nerve fibers so the client will not be aware of swelling.

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Option A: When an infant is crying, the fontanels may look like they are bulging.

Option C: The client in Option C can wait to be seen within the first hour.

Option D: The client in Option D does not have a life-threatening condition but will still require immediate pain relief.

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